Match term to definition
1-100 of 100
Select a definition to match it with its term
Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and
medical treatments for dehydration in a 36-month-old child? (Select all that apply.)
A.Record wet diapers.
B.Assess for sunken fontanels.
C.Examine skin turgor.
D.Observe mucous membranes.
Give this one a go later!
, ACD
All these interventions can be used to evaluate fluid status in children and are
helpful assessment functions (A, C, and D), but the age of the child makes a
fontanel check impractical (B). The posterior fontanel closes at 2 months and the
anterior fontanel closes at 18 months of age.
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring
implementation of the hospital's disaster plan. Specific facts about the nature of this disaster
are not yet known. Which instruction should the charge nurse give to the other staff members
at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received.
Give this one a go later!
D
When faced with an impending disaster, hospital personnel may be alerted but
should continue with current client care assignments until further instructions are
received (D). Evacuation is typically a response of last resort that begins with
clients who are most able to ambulate (A). (B) is premature and is likely to increase
the chaos if incoming casualties are anticipated. (C) is poor utilization of
personnel.
Because of census overload, the charge nurse of an acute care medical unit must select a
client who can be transferred back to a residential facility. The client with which
symptomology is the most stable?
,A.A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus
(MRSA)
B.Pneumonia, with a sputum culture of gram-negative bacteria
C.Urinary tract infection, with positive blood cultures
D.Culture of a diabetic foot ulcer shows gram-positive cocci
Give this one a go later!
A
The client with colonized MRSA (A) is the most stable client, because colonization
does not cause symptomatic disease. The gram-negative organisms causing
pneumonia are typically resistant to drug therapy (B), which makes recovery very
difficult. Positive blood cultures (C) indicate a systemic infection. Poor circulation
places the diabetic with an infected ulcer (D) at high risk for poor healing and
bone infection.
The nurse formulates a nursing diagnosis of pain related to muscle spasms for a client with
extreme lower back pain associated with acute lumbosacral strain. Which is the best
intervention for the nurse to implement?
A.Perform range-of-motion exercises on the lower extremities every 4 hours.
B.Place a small firm pillow under the upper back to flex the lumbar spine gently.
C.Rest in bed with the head of the bed elevated 20 degrees and flex the knees.
D.Position in reverse Trendelenburg with the feet firmly against the foot of the bed.
Give this one a go later!
, C
Resting in bed with the head of the bed elevated 20 degrees and flexing the
knees reduces stress on the lower back muscles (C). Range-of-motion exercises
can result in paravertebral muscle spasms and increased pain (A). Bending the
knees, rather than (B), reduces stress on the lower back. (D) places stress on the
lower back and increases the client's pain.
A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy
with placement of ventilating tubes. Which response by the client indicates that further
teaching is necessary?
A."I will avoid coughing, sneezing, and forceful nose blowing."
B."Swimming can begin on the tenth postoperative day."
C."Any mild discomfort can be managed with acetaminophen."
D."Drainage from my ears is expected after the surgery."
Give this one a go later!
B
The purpose of the ventilating tubes in the tympanic membrane is to equalize
pressure and drain fluid collection from the middle ear. The tube's patency allows
air and water to enter the middle ear, so the client should be reeducated if the
client swims (B) or allows water to enter the external ear. (A, C, and D) reflect
correct responses.
A client is admitted to the mental health unit with a chief complaint of crying, depressed
mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I
can't believe this happened." Which statement by the nurse is most therapeutic?
A."It sounds like you're feeling very sad."
1-100 of 100
Select a definition to match it with its term
Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and
medical treatments for dehydration in a 36-month-old child? (Select all that apply.)
A.Record wet diapers.
B.Assess for sunken fontanels.
C.Examine skin turgor.
D.Observe mucous membranes.
Give this one a go later!
, ACD
All these interventions can be used to evaluate fluid status in children and are
helpful assessment functions (A, C, and D), but the age of the child makes a
fontanel check impractical (B). The posterior fontanel closes at 2 months and the
anterior fontanel closes at 18 months of age.
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring
implementation of the hospital's disaster plan. Specific facts about the nature of this disaster
are not yet known. Which instruction should the charge nurse give to the other staff members
at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received.
Give this one a go later!
D
When faced with an impending disaster, hospital personnel may be alerted but
should continue with current client care assignments until further instructions are
received (D). Evacuation is typically a response of last resort that begins with
clients who are most able to ambulate (A). (B) is premature and is likely to increase
the chaos if incoming casualties are anticipated. (C) is poor utilization of
personnel.
Because of census overload, the charge nurse of an acute care medical unit must select a
client who can be transferred back to a residential facility. The client with which
symptomology is the most stable?
,A.A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus
(MRSA)
B.Pneumonia, with a sputum culture of gram-negative bacteria
C.Urinary tract infection, with positive blood cultures
D.Culture of a diabetic foot ulcer shows gram-positive cocci
Give this one a go later!
A
The client with colonized MRSA (A) is the most stable client, because colonization
does not cause symptomatic disease. The gram-negative organisms causing
pneumonia are typically resistant to drug therapy (B), which makes recovery very
difficult. Positive blood cultures (C) indicate a systemic infection. Poor circulation
places the diabetic with an infected ulcer (D) at high risk for poor healing and
bone infection.
The nurse formulates a nursing diagnosis of pain related to muscle spasms for a client with
extreme lower back pain associated with acute lumbosacral strain. Which is the best
intervention for the nurse to implement?
A.Perform range-of-motion exercises on the lower extremities every 4 hours.
B.Place a small firm pillow under the upper back to flex the lumbar spine gently.
C.Rest in bed with the head of the bed elevated 20 degrees and flex the knees.
D.Position in reverse Trendelenburg with the feet firmly against the foot of the bed.
Give this one a go later!
, C
Resting in bed with the head of the bed elevated 20 degrees and flexing the
knees reduces stress on the lower back muscles (C). Range-of-motion exercises
can result in paravertebral muscle spasms and increased pain (A). Bending the
knees, rather than (B), reduces stress on the lower back. (D) places stress on the
lower back and increases the client's pain.
A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy
with placement of ventilating tubes. Which response by the client indicates that further
teaching is necessary?
A."I will avoid coughing, sneezing, and forceful nose blowing."
B."Swimming can begin on the tenth postoperative day."
C."Any mild discomfort can be managed with acetaminophen."
D."Drainage from my ears is expected after the surgery."
Give this one a go later!
B
The purpose of the ventilating tubes in the tympanic membrane is to equalize
pressure and drain fluid collection from the middle ear. The tube's patency allows
air and water to enter the middle ear, so the client should be reeducated if the
client swims (B) or allows water to enter the external ear. (A, C, and D) reflect
correct responses.
A client is admitted to the mental health unit with a chief complaint of crying, depressed
mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I
can't believe this happened." Which statement by the nurse is most therapeutic?
A."It sounds like you're feeling very sad."
